Sexual and urologic complications among men and women with diabetes have historically received relatively little attention from clinicians. Diabetes impacts the function and structure of the lower urinary tract, including the bladder and prostate. Studies suggest that urologic complications resulting from diabetes may be even more common than that of widely recognized microvascular complications, such as retinopathy, neuropathy, or nephropathy. “Diabetes can lead to different types of sexual and urologic complications in both men and women,” says Jeanette S. Brown, MD (Table 1). “These include urinary incontinence (UI), poor bladder emptying, sexual dysfunction, lower urinary tract symptoms (LUTS), and urinary tract infections (UTIs). Treatment options are available for many of these sexual and urologic complications. Unfortunately, these problems often go unaddressed because patients oftentimes will not discuss these issues with their clinicians.” Caring for Women: Lower Urinary Tract Symptoms Urinary incontinence has been estimated to be more common in women with type 2 diabetes than in women with normal glucose levels (Table 2). There is also evidence that women with pre-diabetes are at higher risk for incontinence. The clinical diagnosis of UI—and more broadly, LUTS—is typically based on a variety of factors, and Dr. Brown says that clinicians can be proactive by paying attention to patient complaints when they arise. “It can often be difficult for women to speak up when they develop issues like UI, LUTS, or UTIs, but we should be asking them about these symptoms regularly during office visits,” Dr. Brown says. “When symptoms are identified, we can then take that opportunity to educate patients about the possible treatment options that are available to manage these...

Studies have shown that patients with localized prostate cancer have favorable long-term overall survival rates and cancer-specific survival regardless of the treatment that is selected. Few prospective, randomized trials have looked at differences in survival outcomes between radical prostatectomy and external-beam radiation therapy. As a result, the decision-making process for clinicians and patients shifts. Treatment decisions become more about predicting functional outcome than about survival. Investigations with short-term and intermediate follow-up have identified incremental differences in functional outcome between patients undergoing prostatectomy and those receiving radiotherapy. While much is known about what happens the first several years after treatment, less is known about outcomes extending beyond 5 years. “Most patients live 10 to 20 years after treatment,” says David F. Penson, MD, MPH. “A careful evaluation of long-term functional outcomes can help us better understand the experience of men living with a diagnosis of prostate cancer.” Long-Term Function of Prostatectomy Vs Radiotherapy In a study published in the New England Journal of Medicine, Dr. Penson and colleagues prospectively compared urinary, sexual, and bowel function in 1,655 men with clinically localized prostate cancer, 1,164 of whom underwent prostatectomy, while 491 received radiotherapy. The study team also examined the extent to which men were bothered by declines in function at 15 years after prostatectomy or radiotherapy. Most of the men were in their 60s when they first received treatment. According to the results, men receiving prostatectomy were significantly more likely than those in the radiotherapy group to report urinary leakage and erectile dysfunction at 2 and 5 years after treatment. However, these problems increased in both groups over time, including 15...

As the elderly population in the United States continues to grow rapidly, it’s expected that the prevalence of fecal incontinence will also increase substantially. The condition is highly prevalent in both older men and women. Fecal incontinence can significantly decrease quality of life because patients often find it difficult to hide odor issues. In many cases, they develop depression and become socially isolated. Many sufferers live with the condition for 5 years or longer before seeking treatment. Despite its prevalence and harmful impact on patients and their caregivers, fecal incontinence remains understudied in clinical research. Furthermore, few studies have looked at its economic burden in the U.S. Quantifying Costs of Fecal Incontinence In Diseases of the Colon & Rectum, my colleagues and I had a study published that aimed to quantify per-patient annual costs associated with fecal incontinence. Patients with the condition were mailed a survey in 2010 to collect information on their sociodemographic characteristics, symptoms, and use of medical and non-medical resources for fecal incontinence. The analysis included 332 adult patients who had fecal incontinence for more than a year with at least monthly leakage of solid, liquid, or mucous stool. Three categories of cost were examined in the study: 1) direct medical costs, including dollars spent for diagnosis, treatment, and management of the condition; 2) direct non-medical costs, including dollars spent for non-medical resources, such as protective products or transportation to care; and 3) indirect costs, such as accountable dollars from loss of productivity. Unit costs were determined based on standard Medicare reimbursement rates, national average wholesale prices of medications, and estimates from other relevant sources. According...

To successfully manage type 2 diabetes in older adults, clinicians must recognize and understand the unique challenges these individuals face. While the benefits of tight glycemic control in older adults are similar to those of younger patients, physicians need to understand that barriers may interfere with older adults’ ability to perform self-care before setting goals of care. When establishing overall health goals, there must be a balance between the perceived benefits of tight glycemic control and the risks of treatment, such as hypoglycemia. Diabetes management plans should be formulated for older adults after careful consideration of their health and social backgrounds. Recognize Comorbidities Older adults with diabetes are at higher risk for many medical conditions that are not typically associated with diabetes, including cognitive impairment, depression, and functional decline. Identifying these conditions before forming management plans is essential. Early identification of subtle cognitive dysfunction, especially executive dysfunction, can enable practitioners to simplify treatment plans to avoid complications. Executive functions are important for diabetes self-care. Depression in older adults with diabetes has been linked to poor glycemic control, decreased adherence to treatment strategies, increased functional disability, and higher mortality in clinical studies. To screen for depression, the Geriatric Depression Scale can be of help. Older people with diabetes are also at increased risk of falls due to lower limb dysfunction, cardiovascular disease, polypharmacy, and impaired balance. Since improved glycemic control can help prevent progression of diabetes-related microvascular and macrovascular complications, it may also decrease the fall risks. On the other hand, it’s important to prevent hypoglycemia as it may manifest as dizziness or weakness and increase fall risks. These patients...

American investigators suggest that a prophylactic midurethral sling inserted during vaginal prolapse surgery appears to lower urinary incontinence rates at 3 and 12 months. Among women who received the sling, the urinary incontinence rates at 3 and 12 months were 23.6% and 27.3%, respectively, com­pared with 49.4% and 43.9% rates for women who received sham incisions during surgery. Abstract: New England Journal of Medicine, June 21, 2012...